POLICY STATEMENT

Organizational Principles to Guide and Reducing the Risk of HIV Infection Define the Child Health Care System and/or Associated With Illicit Drug Use Improve the Health of All Children

Committee on Pediatric AIDS

ABSTRACT Substance abuse, specifically the use of illicit drugs that are administered intrave- nously, continues to play a role in the transmission of human immunodeficiency virus type 1 (HIV-1) among adolescents and young adults (youth). Risks of HIV-1 infection may result from direct exposure to contaminated blood through sharing of injection drug equipment and from unsafe sexual practices (while under the influence of drugs and/or in exchange for drugs). Reducing the risk of HIV-1 infection that is associated with illicit drug use requires prevention education and prompt engagement in treatment. Providing patients with education, instruction on decontamination of used injection drug equipment, improved access to sterile syringes and needles, and postexposure prophylaxis may decrease their risk of acquiring HIV-1 infection. Pediatricians should assess risk behaviors as part of every health care encounter, including queries about tobacco, alcohol, and mar- ijuana use. The risks and benefits of postexposure prophylaxis with antiretroviral drugs should be considered for youth with a single recent (within 72 hours) high-risk exposure to HIV-1 through sharing needles/syringes with an HIV-1–infected individ- ual or having unprotected intercourse with an individual who engages in injection drug use. Such prophylaxis must be accompanied by risk-reduction counseling, ap- propriate referrals for treatment, and evaluation for pregnancy and associated sexually transmitted infections. There is an urgent need for more substance-abuse prevention and treatment programs, legislation that facilitates unencumbered access to sterile syringes, and expedient availability of reproductive health care services for sexually active youth, including voluntary HIV-1 counseling and testing.

www.pediatrics.org/cgi/doi/10.1542/ peds.2005-2750 BACKGROUND doi:10.1542/peds.2005-2750 Illicit drug use continues to play a major role in the transmission of human All policy statements from the American immunodeficiency virus type 1 (HIV-1) in the United States. Injection drug users, Academy of Pediatrics automatically men who have sex with men and engage in injection drug use, and heterosexuals expire 5 years after publication unless who have sexual contact with an injection drug user were responsible for 23% of reaffirmed, revised, or retired at or before that time. reported acquired immunodeficiency syndrome (AIDS) cases among adults and Key Words 1 adolescents in 2003. Among youth 13 to 24 years of age, these transmission human immunodeficiency virus, HIV-1, categories accounted for 13.4% of AIDS cases in 2003. Of the approximately adolescents, youth, substance abuse, 40 000 new HIV-1 infections each year in the United States, an estimated 50% injection drug use, postexposure prophylaxis, needle exchange occur among individuals younger than 25 years.2–4 The most common mode of Abbreviation acquisition of HIV-1 infection among youth is sexual contact. Young women 13 to PEP—postexposure prophylaxis 24 years of age are infected most often by heterosexual exposure to partners with PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2006 by the HIV-1 infection. Heterosexual contact was reported by 52% of females as their American Academy of Pediatrics primary risk factor for HIV-1 infection, and 15% reported “no identified risk”

566 AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.aappublications.org/news by guest on October 2, 2021 because they did not know that their partner was in- identify substance abuse and other high-risk activities in fected with HIV-1.3 Male-to-male sex accounts for 33% adolescents. Even in the absence of current high-risk of HIV-1 infections in males 13 to 19 years of age and activities, pediatricians should discuss approaches that 62% of HIV-1 infections in males 20 to 24 years of age.3 families can use to facilitate an interactive and ongoing These young men commonly fail to disclose their sexual dialogue regarding the use of illicit drugs, alcohol, and behavior for fear of rejection and alienation.4 Of signif- tobacco products19; the relationship of illicit drug use and icant concern to public health officials and health care unsafe sexual activity; and attendant health-related risks professionals is that these estimates may significantly including the risk of HIV-1 acquisition.20,21 Discussions of underrepresent actual infections. Many youth have not substance abuse19 fit in appropriately with routine antic- been tested, and those who are aware of their HIV-1 ipatory guidance for adolescents, including discussions infection status may not seek medical care, which poses of sexuality,22 sexual orientation,23 condom use,24 and a risk of unintended transmission and disease progres- contraception. These topics need to be discussed with a sion. For example, the prevalence of HIV-1 infection in a nonjudgmental approach,20,23 with careful attention to cohort of approximately 3500 young men who have sex local laws concerning confidentiality.18,25,26 Pediatricians with men in 7 US cities was found to be 7.2%. Approx- should also familiarize themselves with state laws that imately three fourths of these HIV-1–infected young govern the delivery of medical services to minor youth.18 men (15–22 years of age) were unaware of their HIV-1 Assurance of confidentiality is important to youth who serostatus.5 may be reticent to share information regarding high-risk Risk factors for injection drug use may include to- behaviors, depression, or sexual-identity concerns for bacco, alcohol, and marijuana use6–8 and depression.9 fear of disclosure to parents. A confidentiality policy Several recent studies have identified an association presented in the presence of youth and their parent(s) with illicit drug and alcohol use as well as high-risk may encourage young people to share personal informa- sexual activity in youth who engage in body-modifica- tion more openly.26 tion practices, including tattoos, body piercing, and Access to treatment programs is essential for youth branding.10–12 Drug dependence among youth also is as- with substance-abuse problems. Adolescent-specific pro- sociated with a history of childhood sexual abuse.13 grams are effective, but ongoing intervention is needed There is a direct risk of HIV-1 transmission associated to avoid relapse.27 Effective treatment for such youth is with sharing needles that are used to inject intravenous hampered by the dearth of available and affordable am- drugs or to apply tattoos and reusing tattoo ink(s). Youth bulatory and inpatient programs.27,28 Of an estimated 1.4 may unintentionally put themselves at risk of acquiring million youth 12 to 17 years of age who required treat- HIV-1 by engaging in sexual activity while under the ment for substance abuse in 2002, only 10% received influence of illicit drugs or alcohol. In this scenario, services.29 Only 7% of substance-abuse treatment cen- youth may fail to use condoms and perhaps select par- ters provide services for individuals younger than 18 ticularly high-risk sexual partners.14 years.29 The paucity of inpatient treatment facilities for substance abuse poses secondary risks of infection, un- treated mental health issues, and academic failure. Such REDUCING THE RISK OF HIV-1 INFECTION ASSOCIATED WITH facilities need to be more readily accessible,28 and treat- ILLICIT DRUG USE ment needs to be reimbursed adequately to ensure con- Preventing and Treating Illicit Drug Use/Substance Abuse tinued availability of services.30 There also is a need to The development and implementation of reproducible, encourage medical insurance companies to provide ad- efficacious strategies to prevent the onset of substance equate reimbursement to pediatricians who are willing use is critical. These primary prevention efforts should to address substance-abuse problems in their practices. begin early and be directed at children and adolescents who have not yet established a pattern of drug de- Preventing Acquisition of HIV-1 Infection Among Those With a pendence or injection drug use. Initiatives should be Substance-Abuse Problem coordinated and broadly based, with the involvement of families, schools, and community agencies including Education correction services/detention centers. At a community Educational initiatives to reduce health risks that are level, efforts also should be made to reach out to all associated with substance abuse should address all youth. Homeless, runaway, and incarcerated youth are known drugs including alcohol and tobacco. Communi- subpopulations that may be at higher risk. Pediatricians ty-based programs can provide information to users of can and should take a leadership role in these initiatives. injection drugs and other illicit drugs about risky sexual In clinical care settings, pediatricians should routinely behaviors that are linked to transmission and acquisition assess patients for risk of substance use15 and attendant of HIV-1, the relationship between the exchange of sex comorbidities.16 The HEADSS risk-assessment instru- for drugs and HIV-1 infection, and the protection to be ment17 is one of a number18 of useful approaches to gained from the proper use of condoms. Efforts should

PEDIATRICS Volume 117, Number 2, February 2006 567 Downloaded from www.aappublications.org/news by guest on October 2, 2021 be made to encourage cessation or reduction of illicit injection drug use risk behavior.36 Such programs should drug use, promote entry into substance-abuse treatment be considered in other states. programs, to discourage the sharing of injection drug Initiatives with the singular objective of increasing paraphernalia, to educate about safe sex practices, and to access to sterile injection drug equipment remain con- support access to mental health services. When helping troversial, because they do not directly address the youth with substance-abuse problems move into treat- causes and broader consequences of injection drug use. ment, a nonconfrontational, empathetic approach is Despite mounting evidence to counter concerns of esca- needed. Motivational enhancement therapy offers one lating injection drug use resulting from unencumbered such approach to helping youth accept care for sub- access to sterile equipment, the controversy remains an stance-abuse problems.15 The pediatrician can be an in- impediment for some states and cities to enact legislation valuable educational resource to youth-serving commu- to provide this service. Syringe-exchange programs re- nity-based organizations. duce the risk of HIV-1 acquisition from use of shared needles,37,38 and their association with other counseling Decontamination of Used Injection Drug Equipment and HIV-1 risk-reduction services leads to reduction of A significant proportion of drug-dependent individuals high-risk sexual behaviors as well, further enhancing are unwilling or unable to stop injection drug use and do the effectiveness of such programs to limit the spread of not have access to new or sterile needles and syringes. HIV-1 among those who engage in injection drug use as Bleach disinfection of injection equipment is an im- well as their sexual partners.39,40 Syringe-exchange pro- portant strategy to reduce the risk of HIV-1 infection grams do not lead to an increase in injection drug use,41 from reusing or sharing needles and syringes when no nor do they lead to formation of social networks that safer options are available.31 In a recent study of injec- might enhance transmission of HIV-1 and other diseas- tion drug users, rinsing syringes with a 1:10 bleach so- es.42 Although prospective, randomized, controlled trials lution (bleach to water) resulted in no recovery of viable have not been feasible and not all programs have been HIV-1.32 The disinfection procedure requires flushing the able to demonstrate a protective effect against the spread barrel of the syringe at least 2 times with a minimum of of HIV-1 infection, the number of studies that have 30 seconds’ exposure to the solution, followed by 1 to 2 demonstrated benefits from needle-exchange programs, rinses with clean water before reuse.32 particularly those conducted within the context of com- prehensive drug treatment, is now sufficient to support Access to Sterile Syringes and Needles efforts to make such programs more widely available.43 The public health risks associated with shared use of Access to sterile equipment is most likely to be suc- injection drug paraphernalia have led many national cessful in reducing the risk of HIV-1 transmission if it and governmental entities not only to advocate for ac- operates in the context of a comprehensive program that cess to sterile syringes and needles but also to remove provides counseling, opportunities to be engaged in pre- existing state laws that invoke criminal penalties for vention education, and opportunities to receive health possession of injection drug equipment.33 In many states, care services and if it emphasizes treatment. The provi- these laws have been crafted to provide a potentially sion of clean needles and syringes to injection drug users legal safety net for physicians and pharmacists who pre- who have access to treatment but are unwilling or un- scribe or dispense needles and syringes. It is currently able to enter treatment or remain abstinent while in illegal for physicians to prescribe injection equipment for treatment may reduce the acquisition or transmission of injection drug users in only 2 states: Delaware and Kan- HIV-1 infection. Syringe-exchange programs are cur- sas. It is illegal for pharmacists to fill prescriptions for rently available in 31 states, the District of Columbia, injection equipment for injection drug users in 4 states: and Puerto Rico. Referral to substance-abuse programs Delaware, Kansas, Georgia, and Hawaii.34 was provided by 95% of the syringe-exchange programs. In 2000, New Hampshire, New York, and Rhode Is- Injection drug users who are referred to substance-abuse land adopted new syringe laws that partially or com- treatment programs by syringe-exchange programs have pletely removed the requirement for a prescription to short-term outcomes comparable to those referred by purchase syringes as well as legal penalties for syringe other resources.34 possession.35 In Rhode Island, the prescription of sy- ringes to patients who are injection drug users is pro- Postexposure Prophylaxis vided in concert with an agreement to document this In situations in which an HIV-1–uninfected adolescent care in the medical record, to make syringe prescription has a single recent exposure (within 72 hours) to HIV-1 a part of the patient’s ongoing medical care, to include from sharing injection drug equipment with an HIV-1– other harm-reduction strategies in the patient’s care, to infected individual, some experts will consider providing assist patients in disposing of used syringes safely, and to postexposure prophylaxis (PEP).44 The risk of HIV-1 notify the pharmacy at the time of initial prescription.36 transmission for each episode of needle or syringe expo- That program seems to be associated with reductions in sure is estimated at 0.67%. Pediatricians should be able

568 AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.aappublications.org/news by guest on October 2, 2021 to provide their patients who have an at-risk exposure porate dialogue about substance use and sexual through injection drug use access to a system for prompt activity in their homes. 45 evaluation, counseling, and possible PEP. However, for ● Pediatricians should advocate for youth-friendly adolescents who continue needle sharing and, thus, po- substance-abuse treatment facilities that are able to tentially expose themselves to HIV-1, PEP is not rou- accommodate all youth, including those who are tinely recommended, and behavioral interventions to uninsured, underinsured, and undocumented. Pe- reduce repeated exposure are more appropriate. Current diatricians should familiarize themselves with re- US Public Health Service guidelines include consider- ferral sources for substance-abuse prevention and ation of PEP with combination antiretroviral therapy in treatment and mental health services. patients after injection drug use if the likelihood of shared needles between an HIV-1–uninfected and HIV- 3. Preventing acquisition of HIV-1 infection 1–infected person is significant, the event is sporadic ● Pediatricians should assess HIV-1–related risk be- rather than frequent, and combination antiretroviral haviors as part of every health care encounter. therapy is begun within 72 hours of exposure.46 PEP ● might also be considered for sexual exposure to an HIV- Pediatricians should advocate for seamless access 1–infected individual who engages in injection drug use. to reproductive health care services for youth and Additional information regarding PEP among pediatric be aware of the close association of illicit drug use and adolescent patients can be obtained from a recent and high-risk sexual activity. AAP clinical report.47 If PEP is provided, it is critical that ● Pediatricians should advocate for unencumbered risk-reduction counseling related to injection drug use access to sterile syringes and improved knowledge and referral to appropriate substance-abuse treatment be about decontamination of injection equipment. provided concomitantly. Youth with possible percutane- Physicians should be knowledgeable about their ous HIV-1 exposure attributable to injection drug use states’ statutes regarding possession of syringes and also should be assessed for hepatitis B and hepatitis C needles and available mechanisms for procure- virus infection and, if not previously fully immunized, ment. These programs should be encouraged, ex- given hepatitis B vaccine. panded, and linked to drug treatment and other HIV-1 risk-reduction education. It is important that these programs be conducted within the context of CONCLUSIONS AND RECOMMENDATIONS continuing research to document effectiveness and The transmission of HIV-1 is one of many adverse con- clarify factors that seem linked to desired out- sequences of illicit drug use. Initiatives to reduce the risk comes. of HIV-1 transmission should include the following. ● For youth with a single recent (within 72 hours) 1. Engaging youth in care high-risk exposure to HIV-1 through either sharing needles/syringes with an HIV-1–infected individ- ● Engagement of a youth in his or her own health ual or engaging in unprotected intercourse with an care is critical to achieving a physician-patient re- individual who engages in injection drug use, the lationship in which honest discussions about high- risks and benefits of PEP with antiretroviral drugs risk behavior are possible. Pediatricians should re- should be considered. Such prophylaxis must be view their state laws governing health care services accompanied by risk-reduction counseling and re- available to minors without parental consent. Con- ferral to appropriate substance-abuse treatment. fidentiality policies should be developed and dis- cussed with both the youth and parent(s) present. COMMITTEE ON PEDIATRIC AIDS, 2003–2004 Pediatricians should advocate for services (mobile Mark W. Kline, MD, Chairperson vans, drop-in centers) that can engage hard-to- Robert J. Boyle, MD reach youth populations such as homeless and Donna Futterman, MD runaway youth. Peter L. Havens, MD 2. Preventing and treating substance abuse *Lisa M. Henry-Reid, MD Susan King, MD ● Primary prevention activities in the community and in care settings should be directed at families of CONSULTANT preadolescents and youth and should promote Lorry Rubin, MD healthy lifestyles. Physicians should support frank discussion between families and their children to STAFF avoid the initiation of illicit drug use, including Jeanne Christensen Lindros, MPH alcohol and tobacco use. Parents also should be given information and strategies on ways to incor- *Lead author

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Updated Information & including high resolution figures, can be found at: Services http://pediatrics.aappublications.org/content/117/2/566 References This article cites 39 articles, 9 of which you can access for free at: http://pediatrics.aappublications.org/content/117/2/566#BIBL Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Infectious Disease http://www.aappublications.org/cgi/collection/infectious_diseases_su b HIV/AIDS http://www.aappublications.org/cgi/collection/hiv:aids_sub Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.aappublications.org/site/misc/Permissions.xhtml Reprints Information about ordering reprints can be found online: http://www.aappublications.org/site/misc/reprints.xhtml

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